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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700683
Report Date: 10/22/2020
Date Signed: 10/22/2020 04:24:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ACC MAPLE TREE VILLAGEFACILITY NUMBER:
342700683
ADMINISTRATOR:FREDRICKSON, KYLE COTTERFACILITY TYPE:
740
ADDRESS:7579 MAPLE TREE WAYTELEPHONE:
(916) 395-7579
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:125CENSUS: 32DATE:
10/22/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:16 PM
MET WITH:Kyle FredricksonTIME COMPLETED:
04:22 PM
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Licensing Program Analyst (LPA) Suong Teh contacted the facility via telephone to commence an unannounced tele-visit on 10/22/2020 @1616 hours due to COVID-19 and pre-cautionary measures. LPA spoke with Executive Director Kyle Fredrickson and discussed the purpose of the call and the elements of this type of visit. Today's date for the purpose of delivering an Order to Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion From Facility.


LPA Teh spoke with Kyle Fredickson and explained the purpose of today's visit. Staff, Kim Atkinson is excluded as a result of her actions related to this facility.

LPA Teh discussed the Order to Facility Staff of Immediate Exclusion from the Facility and explained that staff, Kim Atkinson cannot come to the facility after the five day protective order is expired and cannot be allowed to work, be present and/or live in a CCL licensed facility or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services.

The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted with Kyle Fredrickson via telephone and a copy of this report was provided via email.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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